Editorial Patient Compliance Are We Wasting Our Time and Don't Know It? Physicians and behavioral scientists investigating the extent to which people follow their doctors orders or recommendations have used the terms compliance or adherence to describe the phenomenon. Studies over the past 20 years have consistently shown that (1) 40 to 50% of patients do not use medicines as prescribed (1); (2) compliance is not associated with age, sex, educational level, economic status, or personality traits, or with characteristics of the disease, including diagnosis (except mental illness and alcoholism) or severity or frequency of symptoms (4); (3) physicians cannot predict better than chance alone which of their patients will or will not comply (2, 3). These unsettling findings, which fly in the face of common sense, turn out to be true because compliance is not associated with many of the "common sense" factors we use in everyday life to make predictions about other peoples' behavior. These disturbing findings further suggest that whatever strategies we adopt to improve compliance should be applied to all our patients regardless of how likely we think they are to comply. Reviews of the extensive literature on compliance show that there are several groups of factors that are associated with improved compliance (4). These include: (1) characteristics of the regimen such as shorter duration, simplicity, and minimization of behavior change required of the patient; (2) family characteristics such as stability, smaller size, and support for the patient's compliance; (3) patient health beliefs that the disease is serious, that the patient is vulnerable to it, that the proposed therapy will be effective, and that there are no barriers or reasons not to implement the treatment plan; (4) patient understanding of the rationale for treatment and the details of the treatment plan; (5) characteristics of the patient-clinician relationship including continuity of care, short waiting time in the doctor's office, giving written instructions to the patient, close supervision by the clinician of the patient's use of medicine, the meeting of patient expectations, and patient satisfaction. The article by Rand and colleagues in this issue (5) sheds light on two problems (1) physician-patient interaction; (2) as1376
sessment of noncompliance. Regarding that patient's goals for treatment often the first point, despite efforts to enhance differ from the physician's, that patients compliance, over 70070 of the patients have highly variable lifestyles that affect with chronic obstructive lung disease in the acceptability of treatment plans, and the clinical trial did not comply with the that patients have an enormous variety medical regimen they were given. Para- of beliefs and concerns about health and doxically, the demand characteristics medications that may block adherence (wish to please or appear cooperative) of (9). Overcoming these barriers requires the interaction with the physician were that physicians change the way they elicso high for 150J0 of the patients that they it information. It requires that they use deliberately dumped their medications so techniques that uncover barriers patients as to appear to be following the physi- have to following the therapeutic plan cian's orders. The article by Rand and and enable physician and patient to work colleagues also gives us solid informa- out solutions together. The narrow defition about the need for better research nition of compliance as "getting them to methodologies used to measure compli- take the medicine" has to be broadened ance. When demand characteristics are with concepts of open communication high, both self-report of medicine-taking about both the patient's and the physiand physically weighingthe canister con- cian's concerns and objectives, shared taining the medicine are inadequate responsibility and mutual agreement on means for determining actual use of the medical regimen. A shift is needed medicine, i.e., how much is taken and in the way physicians prescribe and counwhen. Although we have long known the sel patients, away from an exclusive foformer, wehave not known the latter. We cus on the clinician's goals (i.e., to use can infer from their work that because particular medicines in a predetermined physicians in practice or in clinical trials schedule) to one that also includes the may be unaware of the underuse of medi- patient's goals and concerns (e.g., fitting cations by patients, they may underesti- in with school or work schedules or not mate the effectiveness of drug regimens. disrupting daily life patterns). Thus phyThis in turn may lead to prescribing sician and patient can derive a medical regimen of minimum complexity and duerrors. Much of the early literature on com- ration that will achievethe patient's goals. pliance conceived of the problem as sim- This process of joint development of the ply persuading the patient to follow the therapeutic plan has been called codoctor's orders. While reviews of the liter- management, patient self-management, ature suggest that interventions based on or physician-patient partnership, and rethis goal can increase adherence to the cent studies in asthma have shown that medical regimen to some extent (1), there such approaches can have an appreciais a growing recognition that to improve ble effect on decreasing morbidity and significantly the way in which they use improving daily functioning of patients medicines and otherwise manage disease, (10, 11). For those physicians who forego the patients must be actively involved in the process of determining the therapeutic idea that complianceis achieved by tellplan. The difficulty with the earlier con- ing the patient what to do in favor of a cept of compliance is that it assumes (1) physician-patient partnership that enpatients will put aside their own personal courages self-management, an interactive beliefs or objectives in order to follow process of education ceases to be a frill a physician's treatment prescriptions; (2) or appendage to the physician-patient enthat physicians can offer prescriptions counter; rather, it becomes the core (11). that remain appropriate over a wide ar- In such an approach, the physician no ray of possible changes in patients' per- longer assumes an authoritarian or paternalistic model of behavior (I know what sonal or medical circumstances. The research on patient health beliefs is best for you so follow my orders). Rathby Becker and his colleagues (6) and re- er, the physician assumes the role of consearch in self-management of asthma and sultant and teacher using an interactive other chronic diseases (7,8) demonstrates approach that enables and encourages AM REV RESPIR DIS 1992; 146:1376-1377
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EDITORIAL
considerable input from the patient. By having a role in tailoring the regimen to meet their needs and reach their desired outcomes, patients (or families in the case of a child) will be motivated to make greater efforts to follow the therapeutic plan. The key elements in the interaction and communication between physician and patient include (1) eliciting and addressing patients fears and concerns about the disease and the use of medication; (2) providing patients with information and helping them develop the skills needed to control the disease; (3) enhancing patients' sense of control over the disease by verbally reinforcing the desirable actions they take. This collaborative approach creates an atmosphere in which patients and physicians are candid with each other and reach a sufficient level of trust for open communication, constructive negotiation, and consensus to occur. For many physicians, interaction and mutual decision making seems to mean adding time to an already over-extended clinical schedule. However, the idea is not to spend more time but to use existing time differently. If current practice leads to 50070 of patients not doing what they are asked to do, then much of current practice in a very real sense can be called a waste of time. However, we believe that time is not the issue. Physicians tend not to encourage participation by the patient in treatment decisions not because it takes more time but because physicians are not used to behaving in this way. Medical training, which continues to be based primarily on provision of acute care, prepares individuals to act quickly in serious or life-threatening situations in an authoritarian way with passive patients who have little or no choice in the ameliorative steps to be taken. In actual practice, most physicians see people with chronic diseases as part of a long-term relationship in which the patients are not passive (even if they appear to be in the doctor's office) and have the option of ignoring the physician's advice. No physician can anticipate all the situations that can exacerbatea patient's disease. Authoritarian approaches are not likely to be effective because they discount the high degree of independent decision making and adaptive responses required by the patient as circumstances change. If the long-term goal of chronic lung disease management is to enable the patient to live effectively under changing conditions including exacerbations of disease, then it is clear that biomedical science alone is not sufficient to achieve this goal. We need strong interdisciplinary science incorporating contributions
from the behavioral sciences including psychology, sociology, education, communications and public health. There are promising new theoretical approaches in the behavioral sciences being applied to problems of adherence, self-management, and patient-physician communication. One example taken from the field of cognitive psychology will perhaps suffice. Self-regulation can be defined generally as the way people control and adapt their thoughts, emotions, and behavior to changing situations and personal outcomes. Research has identified several psychological processes that underlie patients' ability to control and adapt to continually changing conditions that have an impact on their health (12, 13).Among the key processes that help patients selfregulate successfullyare: (1) setting or adjusting the goals one wishes to achieve; (2) developing new prevention or management strategies to achieve the desired goals; (3) observing and evaluating one's own health functioning (self-monitoring, preferably by objective measures); (4) reacting to one's own success or progress with increased self-confidence (self-efficacy) and motivation to control the disease (12, 13). The findings of self-regulation research may help us to understand that some behavior termed noncompliant may represent a patient's difficulty in self-regulating. For example, patients with asthma who are used to the rapid effects of bronchodilators may make a judgment that inhaled steroids are ineffective because no immediate result is apparent. They may then abandon their use, and feel less confidence in their doctors and in their own ability to manage their illness. Patients make decisions for themselves based on their own perceptions of what works. If physicians recognize this they can guide patients and enable them to make informed decisions. Anticipating some of the problems and outcomes that are likely for patients and working out with them both a plan of action and ways to assess its effectiveness becomes an essential component of the physician-patient interaction. Therapeutic advances in medicine often have come from greater insights into the mechanisms of disease. The Rand paper underscores however, that the advanced knowledge of today's clinicians is literally being "dumped" by their patients. The effectiveuse of these advances by patients will depend upon continued development of insights into the mechanisms of behavior; behavior on the part of physicians that enables them to engage in effective communication and education efficiently,and behavior on the
part of patients that enables them to respond effectivelyto changing health conditions and personal circumstances. Collaborative research including interventions that are based on insights from biomedical and behavioral science offers promise of improved health and greater satisfaction for both the patient and the physician. ROBERT B. MELLINS DAVID EVANS
Columbia University College of Physicians and Surgeons Pediatric Pulmonary Division New York, NY BARRY ZIMMERMAN
The Graduate School City University of New York New York, NY NOREEN M. CLARK
Department of Health Education and Health Behavior School of Public Health University of Michigan Ann Arbor, MI References 1. Ley P. Communicating with patients: improving communication, satisfaction and compliance. New York: Chapman and Hall, 1988; 61-3. 2. Charney E, Bynum R, Eldredge D, et al. How well do patients take oral penicillin? A collaborative study in private practice. Pediatrics 1967; 40:188-95. 3. Mushlin AI, Appel FA. Diagnosing potential noncompliance: physician's ability in a behavioral dimension of medical care. Arch Intern Med 1977; 137:318-21. 4. Haynes RB, TaylorDW,Sackett DL, eds. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979. 5. Rand CS, Wise RA, Nides M, et al. MDI adherence in a clinical trial. Am Rev Respir Dis 1992; 146:1559-64. 6. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q 1984; 11:1-47. 7. Clark NM, Feldman CH, Freudenberg N, Millman EJ, Wasilewski Y,ValleI. Developingeducation for children with asthma through study of self-management behavior. Health Educ Q 1980; 7:278-96. 8. Clark NM, Becker MH, Janz NK, Lorig K, Rakowski W, Anderson L. Self-management of chronic disease by older adults: a review and questions for research. J Aging Health 1991; 3:3-27. 9. Korsch BM, Negrete V. Doctor-patient communication. Sci Am 1972; 227:66-74. 10. Wilson-Pessano SR, Mellins RB. Workshop on asthma self-management: summary of workshop discussion. J Allergy Clin Immunol 1987; 80:487-91. 11. Mellins RB. Patient education is key to successful clinical management of asthma. J Respiratory Disease 1989; (Suppl:S47-52). 12. Clark NM, Zimmerman BJ. A social cognitive view of self-regulated learning about health. Health Educ Res 1990; 5:371-9. 13. Ewart, CK. Social action theory for public health psychology. Am Psychol 1991; 46:931-46.
sessment of noncompliance. Regarding that patient's goals for treatment often the first point, despite efforts to enhance differ from the physician's, that patients compliance, over 70070 of the patients have highly variable lifestyles that affect with chronic obstructive lung disease in the acceptability of treatment plans, and the clinical trial did not comply with the that patients have an enormous variety medical regimen they were given. Para- of beliefs and concerns about health and doxically, the demand characteristics medications that may block adherence (wish to please or appear cooperative) of (9). Overcoming these barriers requires the interaction with the physician were that physicians change the way they elicso high for 150J0 of the patients that they it information. It requires that they use deliberately dumped their medications so techniques that uncover barriers patients as to appear to be following the physi- have to following the therapeutic plan cian's orders. The article by Rand and and enable physician and patient to work colleagues also gives us solid informa- out solutions together. The narrow defition about the need for better research nition of compliance as "getting them to methodologies used to measure compli- take the medicine" has to be broadened ance. When demand characteristics are with concepts of open communication high, both self-report of medicine-taking about both the patient's and the physiand physically weighingthe canister con- cian's concerns and objectives, shared taining the medicine are inadequate responsibility and mutual agreement on means for determining actual use of the medical regimen. A shift is needed medicine, i.e., how much is taken and in the way physicians prescribe and counwhen. Although we have long known the sel patients, away from an exclusive foformer, wehave not known the latter. We cus on the clinician's goals (i.e., to use can infer from their work that because particular medicines in a predetermined physicians in practice or in clinical trials schedule) to one that also includes the may be unaware of the underuse of medi- patient's goals and concerns (e.g., fitting cations by patients, they may underesti- in with school or work schedules or not mate the effectiveness of drug regimens. disrupting daily life patterns). Thus phyThis in turn may lead to prescribing sician and patient can derive a medical regimen of minimum complexity and duerrors. Much of the early literature on com- ration that will achievethe patient's goals. pliance conceived of the problem as sim- This process of joint development of the ply persuading the patient to follow the therapeutic plan has been called codoctor's orders. While reviews of the liter- management, patient self-management, ature suggest that interventions based on or physician-patient partnership, and rethis goal can increase adherence to the cent studies in asthma have shown that medical regimen to some extent (1), there such approaches can have an appreciais a growing recognition that to improve ble effect on decreasing morbidity and significantly the way in which they use improving daily functioning of patients medicines and otherwise manage disease, (10, 11). For those physicians who forego the patients must be actively involved in the process of determining the therapeutic idea that complianceis achieved by tellplan. The difficulty with the earlier con- ing the patient what to do in favor of a cept of compliance is that it assumes (1) physician-patient partnership that enpatients will put aside their own personal courages self-management, an interactive beliefs or objectives in order to follow process of education ceases to be a frill a physician's treatment prescriptions; (2) or appendage to the physician-patient enthat physicians can offer prescriptions counter; rather, it becomes the core (11). that remain appropriate over a wide ar- In such an approach, the physician no ray of possible changes in patients' per- longer assumes an authoritarian or paternalistic model of behavior (I know what sonal or medical circumstances. The research on patient health beliefs is best for you so follow my orders). Rathby Becker and his colleagues (6) and re- er, the physician assumes the role of consearch in self-management of asthma and sultant and teacher using an interactive other chronic diseases (7,8) demonstrates approach that enables and encourages AM REV RESPIR DIS 1992; 146:1376-1377
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EDITORIAL
considerable input from the patient. By having a role in tailoring the regimen to meet their needs and reach their desired outcomes, patients (or families in the case of a child) will be motivated to make greater efforts to follow the therapeutic plan. The key elements in the interaction and communication between physician and patient include (1) eliciting and addressing patients fears and concerns about the disease and the use of medication; (2) providing patients with information and helping them develop the skills needed to control the disease; (3) enhancing patients' sense of control over the disease by verbally reinforcing the desirable actions they take. This collaborative approach creates an atmosphere in which patients and physicians are candid with each other and reach a sufficient level of trust for open communication, constructive negotiation, and consensus to occur. For many physicians, interaction and mutual decision making seems to mean adding time to an already over-extended clinical schedule. However, the idea is not to spend more time but to use existing time differently. If current practice leads to 50070 of patients not doing what they are asked to do, then much of current practice in a very real sense can be called a waste of time. However, we believe that time is not the issue. Physicians tend not to encourage participation by the patient in treatment decisions not because it takes more time but because physicians are not used to behaving in this way. Medical training, which continues to be based primarily on provision of acute care, prepares individuals to act quickly in serious or life-threatening situations in an authoritarian way with passive patients who have little or no choice in the ameliorative steps to be taken. In actual practice, most physicians see people with chronic diseases as part of a long-term relationship in which the patients are not passive (even if they appear to be in the doctor's office) and have the option of ignoring the physician's advice. No physician can anticipate all the situations that can exacerbatea patient's disease. Authoritarian approaches are not likely to be effective because they discount the high degree of independent decision making and adaptive responses required by the patient as circumstances change. If the long-term goal of chronic lung disease management is to enable the patient to live effectively under changing conditions including exacerbations of disease, then it is clear that biomedical science alone is not sufficient to achieve this goal. We need strong interdisciplinary science incorporating contributions
from the behavioral sciences including psychology, sociology, education, communications and public health. There are promising new theoretical approaches in the behavioral sciences being applied to problems of adherence, self-management, and patient-physician communication. One example taken from the field of cognitive psychology will perhaps suffice. Self-regulation can be defined generally as the way people control and adapt their thoughts, emotions, and behavior to changing situations and personal outcomes. Research has identified several psychological processes that underlie patients' ability to control and adapt to continually changing conditions that have an impact on their health (12, 13).Among the key processes that help patients selfregulate successfullyare: (1) setting or adjusting the goals one wishes to achieve; (2) developing new prevention or management strategies to achieve the desired goals; (3) observing and evaluating one's own health functioning (self-monitoring, preferably by objective measures); (4) reacting to one's own success or progress with increased self-confidence (self-efficacy) and motivation to control the disease (12, 13). The findings of self-regulation research may help us to understand that some behavior termed noncompliant may represent a patient's difficulty in self-regulating. For example, patients with asthma who are used to the rapid effects of bronchodilators may make a judgment that inhaled steroids are ineffective because no immediate result is apparent. They may then abandon their use, and feel less confidence in their doctors and in their own ability to manage their illness. Patients make decisions for themselves based on their own perceptions of what works. If physicians recognize this they can guide patients and enable them to make informed decisions. Anticipating some of the problems and outcomes that are likely for patients and working out with them both a plan of action and ways to assess its effectiveness becomes an essential component of the physician-patient interaction. Therapeutic advances in medicine often have come from greater insights into the mechanisms of disease. The Rand paper underscores however, that the advanced knowledge of today's clinicians is literally being "dumped" by their patients. The effectiveuse of these advances by patients will depend upon continued development of insights into the mechanisms of behavior; behavior on the part of physicians that enables them to engage in effective communication and education efficiently,and behavior on the
part of patients that enables them to respond effectivelyto changing health conditions and personal circumstances. Collaborative research including interventions that are based on insights from biomedical and behavioral science offers promise of improved health and greater satisfaction for both the patient and the physician. ROBERT B. MELLINS DAVID EVANS
Columbia University College of Physicians and Surgeons Pediatric Pulmonary Division New York, NY BARRY ZIMMERMAN
The Graduate School City University of New York New York, NY NOREEN M. CLARK
Department of Health Education and Health Behavior School of Public Health University of Michigan Ann Arbor, MI References 1. Ley P. Communicating with patients: improving communication, satisfaction and compliance. New York: Chapman and Hall, 1988; 61-3. 2. Charney E, Bynum R, Eldredge D, et al. How well do patients take oral penicillin? A collaborative study in private practice. Pediatrics 1967; 40:188-95. 3. Mushlin AI, Appel FA. Diagnosing potential noncompliance: physician's ability in a behavioral dimension of medical care. Arch Intern Med 1977; 137:318-21. 4. Haynes RB, TaylorDW,Sackett DL, eds. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979. 5. Rand CS, Wise RA, Nides M, et al. MDI adherence in a clinical trial. Am Rev Respir Dis 1992; 146:1559-64. 6. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q 1984; 11:1-47. 7. Clark NM, Feldman CH, Freudenberg N, Millman EJ, Wasilewski Y,ValleI. Developingeducation for children with asthma through study of self-management behavior. Health Educ Q 1980; 7:278-96. 8. Clark NM, Becker MH, Janz NK, Lorig K, Rakowski W, Anderson L. Self-management of chronic disease by older adults: a review and questions for research. J Aging Health 1991; 3:3-27. 9. Korsch BM, Negrete V. Doctor-patient communication. Sci Am 1972; 227:66-74. 10. Wilson-Pessano SR, Mellins RB. Workshop on asthma self-management: summary of workshop discussion. J Allergy Clin Immunol 1987; 80:487-91. 11. Mellins RB. Patient education is key to successful clinical management of asthma. J Respiratory Disease 1989; (Suppl:S47-52). 12. Clark NM, Zimmerman BJ. A social cognitive view of self-regulated learning about health. Health Educ Res 1990; 5:371-9. 13. Ewart, CK. Social action theory for public health psychology. Am Psychol 1991; 46:931-46.
